Effect of body mass index on maternal morbidity following peripartum hysterectomy.

The objective of this study was to estimate the impact of maternal body mass index (BMI) on maternal morbidity following unscheduled peripartum hysterectomy. A retrospective cohort study of consecutive peripartum hysterectomies at our institution from 1988 through 2012; scheduled hysterectomies were excluded. Medical records were reviewed and maternal, foetal and surgical data collected for each subject. Maternal BMI was categorized by the National Institute of Health classifications for overweight and obese. Statistical analyses included evaluation for trend. A total of 360,774 women delivered at Parkland Hospital during the study period with 665 (1.8 per 1000 deliveries) unscheduled peripartum hysterectomies performed. BMI was available for 635 women. Gestational diabetes, chronic hypertension and pregnancy-related hypertension were significantly higher in all three obesity categories, P = < 0.01. Post-partum complications, such as venous thrombosis and composite surgical morbidity did not differ among BMI groups. Estimated blood loss and units transfused did not differ across the BMI categories, P = 0.42 and P = 0.38, respectively. Increasing BMI was associated with longer surgical times and more wound infections, P = 0.01. These complications should be considered when approaching a peripartum hysterectomy in patients with obesity.

A randomized trial of the effects of coached vs uncoached maternal pushing during the second stage of labor on postpartum pelvic floor structure and function.

OBJECTIVE: The purpose of this study was to determine if refraining from coached pushing during the second stage of labor affects postpartum urogynecologic measures of pelvic floor structure and function. STUDY DESIGN: Nulliparous women at term were randomized to coached (n = 67) vs uncoached (n = 61) pushing. At 3 months' postpartum women underwent urodynamic testing, pelvic organ prolapse examination (POPQ), and pelvic floor neuromuscular assessment. RESULTS: Urodynamic testing revealed decreased bladder capacity (427 mL vs 482 mL, P = .051) and decreased first urge to void (160 mL vs 202 mL, P = .025) in the coached group. Detrusor overactivity increased 2-fold in the coached group (16% vs 8%), although this difference was not statistically significant (P = .17). Urodynamic stress incontinence was diagnosed in the coached group in 11/67 (16%) vs 7/61 (12%) in the uncoached group (P = .42). CONCLUSION: Coached pushing in the second stage of labor significantly affected urodynamic indices, and was associated with a trend towards increased detrusor overactivity.

Association of maternal serum alpha-fetoprotein with persistent placenta previa.

OBJECTIVE: To evaluate the relationship between maternal serum alpha-fetoprotein (MSAFP) and the risk of persistent placenta previa. METHODS: We conducted a retrospective cohort study of singleton pregnancies with sonographic evidence of placenta previa at 15-20 weeks' gestation, between October 1991 and August 2000. Only pregnancies with MSAFP determination at 15-20 weeks' gestation and non-anomalous live-born infants > or =24 weeks' gestation were included. Pregnancies in which Cesarean delivery was performed for placenta previa were considered persistent; this was the primary outcome. RESULTS: Of 275 women with previa at 15-20 weeks' gestation, 33 (12%) had previa at delivery. Trend analysis revealed a greater likelihood of persistent previa with increasing MSAFP values (p=0.01). Mid-trimester MSAFP <1 multiple of the median (MoM) was associated with a decreased incidence of persistence of 4%, significantly less than the risk at > or =1 MoM (16%; p=0.01). CONCLUSIONS: There is an association between increasing MSAFP values and greater likelihood of persistent placenta previa. An MSAFP value <1 MoM is associated with a reduction in the risk of persistence of previa to delivery.

Maternal and fetal artery Doppler findings in women with chronic hypertension who subsequently develop superimposed pre-eclampsia.

OBJECTIVE: To carry out a prospective study of Doppler velocimetry of the fetomaternal circulation in women with chronic hypertension, to evaluate whether the subsequent development of superimposed pre-eclampsia can be predicted. STUDY DESIGN: Serial Doppler studies of the maternal uterine and renal arteries, and fetal middle cerebral and umbilical arteries, were performed at 16-20 and at 28-32 weeks' gestation in 56 women with chronic hypertension. Pulsatility indices were compared using the Wilcoxon rank sum method. A p value of < 0.05 was considered significant. RESULTS: Uterine artery impedance was significantly elevated as early as 16-20 and at 28-32 weeks' gestation, while the cerebroplacental ratio was lower at 28-32 weeks' gestation, in the 14 women who developed superimposed pre-eclampsia. The maternal renal artery impedance remained constant throughout gestation, regardless of the development of pre-eclampsia. CONCLUSIONS: Uterine artery Doppler velocimetry at 16-20 and at 28-32 weeks' gestation showing increased impedance is predictive for the development of superimposed pre-eclampsia in women with chronic hypertension. The cerebroplacental ratio suggested early fetal brain sparing at 28-32 weeks' gestation in these women.

A randomized trial of labor analgesia in women with pregnancy-induced hypertension.

OBJECTIVE: The purpose of this study was to compare the peripartum and perinatal effects of epidural with intravenous labor analgesia in women with pregnancy-induced hypertension. STUDY DESIGN: Women with pregnancy-induced hypertension who had consented to participate were randomized to receive either epidural or intravenous analgesia for labor pain. Both methods were given according to standardized protocols. All women received magnesium sulfate seizure prophylaxis. Obstetric and neonatal outcomes were compared according to intent-to-treat allocation. RESULTS: Seven hundred thirty-eight women were randomized: 372 women were given epidural analgesia, and 366 women were given intravenous analgesia. Maternal characteristics were similar, including the severity of hypertension. Epidural analgesia was associated with a significantly prolonged second-stage labor, an increase in forceps deliveries, and an increase in chorioamnionitis. Cesarean delivery rates and neonatal outcomes were similar. Pain relief was superior with the epidural method. Hypotension required treatment in 11% of women in the epidural group. CONCLUSION: Epidural labor analgesia provides superior pain relief but no additional therapeutic benefit to women with pregnancy-induced hypertension.

Recurrence of preterm birth in singleton and twin pregnancies.

OBJECTIVE: To assess recurrence of preterm birth and its impact on an obstetric population. METHODS: Women with consecutive births at our hospital beginning with their first pregnancy were identified (n = 15,945). The first pregnancy was categorized as delivered between 24 and 34 weeks' gestation or 35 weeks or beyond, singleton or twin, and spontaneous or induced. The risk of preterm delivery in these same women during subsequent pregnancies was then analyzed. RESULTS: Compared with women who delivered a singleton at or beyond 35 weeks' gestation in their first pregnancy, those who delivered a singleton before 35 weeks were at a significant increased risk for recurrence (odds ratio [OR] 5.6, 95% confidence interval [CI] 4.5, 7.0), whereas those who delivered twins were not (OR 1.9, 95% CI 0.46, 8.14). The OR for recurrent spontaneous preterm birth presenting with intact membranes was 7.9 (95% CI 5.6, 11.3) compared with 5.5 (95% CI 3.2, 9.4) with ruptured membranes. Of those women with a recurrent preterm birth, 49% delivered within 1 week of the gestational age of their first delivery and 70% delivered within 2 weeks. Among 15,863 nulliparous women with singleton births at their first delivery, a history of preterm birth in that pregnancy could predict only 10% of the preterm births that ultimately occurred in the entire obstetric population. CONCLUSION: In a population-based study at our hospital, women who initially delivered preterm and thus were identified to be at risk for recurrence ultimately accounted for only 10% of the prematurity problem in the cohort.

Adverse cardiac events after surgery: assessing risk in a veteran population.

OBJECTIVE: To establish rates of and risk factors for cardiac complications after noncardiac surgery in veterans. DESIGN: Prospective cohort study. SETTING: A large urban veterans affairs hospital. PARTICIPANTS: One thousand patients with known or suspected cardiac problems undergoing 1,121 noncardiac procedures. MEASUREMENTS: Patients were assessed preoperatively for important clinical variables. Postoperative evaluation was done by an assessor blinded to preoperative status with a daily physical examination, electrocardiogram, and creatine kinase with MB fraction until postoperative day 6, day of discharge, death, or reoperation (whichever occurred earliest). Serial electrocardiograms, enzymes, and chest radiographs were obtained as indicated. Severe cardiac complications included cardiac death, cardiac arrest, myocardial infarction, ventricular tachycardia, and fibrillation and pulmonary edema. Serious cardiac complications included the above, heart failure, and unstable angina. MAIN RESULTS: Severe and serious complications were seen in 24% and 32% of aortic, 8.3% and 10% of carotid, 11.8% and 14.7% of peripheral vascular, 9.0% and 13.1% of intraabdominal/intrathoracic, 2.9% and 3.3% of intermediate-risk (head and neck and major orthopedic procedures), and 0.27% and 1.1% of low-risk procedures respectively. The five associated patient-specific risk factors identified by logistic regression are: myocardial infarction < 6 months (odds ratio [OR], 4.5; 95% confidence interval [CI], 1.9 to 12.9), emergency surgery (OR, 2.6; 95% CI, 1.2 to 5.6), myocardial infarction > 6 months (OR, 2.2; 95% CI, 1.4 to 3.5), heart failure ever (OR, 1.9; 95% CI, 1.2 to 3.0), and rhythm other than sinus (OR, 1.7; 95% CI, 0.9 to 3.2). Inclusion of the planned operative procedure significantly improves the predictive ability of our risk model. CONCLUSIONS: Five patient-specific risk factors are associated with high risk for cardiac complications in the perioperative period of noncardiac surgery in veterans. Inclusion of the operative procedure significantly improves the predictive ability of the risk model. Overall cardiac complication rates (pretest probabilities) are established for these patients. A simple nomogram is presented for calculation of post-test probabilities by incorporating the operative procedure.

Prolonged pregnancy: induction of labor and cesarean births.

OBJECTIVE: To determine the effects of labor induction on cesarean delivery in post-date pregnancies. MATERIALS AND METHODS: A total of 1325 women who reached 41 weeks' gestation between December 1, 1997, and April 4, 2000, and who were scheduled for induction of labor at 42 weeks were included in this prospective observational study. Cesarean delivery rates were compared between those women who entered spontaneous labor and those who underwent induction. Women with any medical or obstetric risk factors were excluded. A power analysis was performed to determine how many patients would be required to show no effect of labor induction on cesarean delivery with a beta of.8 and an alpha of.05. Approximately 5200 patients would be required, taking an estimated 28 years to accrue at our institution. RESULTS: Admission to delivery was longer (5.7 compared with 11.1 hours, P =.001) and more likely to extend beyond 10 hours (55 compared with 24%, P =.001) in the induction group. Cesarean deliveries were increased in the induced group (19 compared with 14%, P <.001) due to cesarean for failure to progress (14 compared with 8%, P <.001). Independent risk factors for cesarean delivery included nulliparity, undilated cervix prior to labor, and epidural analgesia. Correction for these risk factors using logistic regression analysis revealed that it was the risk factors, and not induction of labor per se, that increased cesarean delivery. CONCLUSION: Risk factors intrinsic to the patient, rather than labor induction itself, are the cause of excess cesarean deliveries in women with prolonged pregnancies.

Intensity of labor pain and cesarean delivery.

Some authors have suggested that the intensity of labor pain may be related to labor dystocia. We performed a secondary analysis of a previously published randomized investigation of the effects of epidural analgesia during labor compared with patient-controlled IV meperidine on cesarean delivery. Two-hundred-fifty-nine women who received patient-controlled IV meperidine were identified for analysis. All women were in spontaneous labor with a singleton, term gestation. Women requiring 50 mg or more of meperidine per hour during labor were compared with those who required <50 mg/h. In addition, their pain scores (visual analog scale) were compared before and after analgesia administration. Pain scores were significantly higher in women requiring 50 mg/h of meperidine (8.7 vs 8.0, P = 0.05), and their labors tended to be longer (9 vs 5 h, P = 0.09). More cesarean deliveries for obstructed labor were performed in women requiring >50 mg/h of meperidine (14% vs 1.4%, P = 0.001). Neonatal outcomes were similar in the two groups.

Antenatal dexamethasone and decreased birth weight.

OBJECTIVE: To test the hypothesis that antenatal dexamethasone treatment to promote fetal lung maturation results in decreased birth weight corrected for gestational age. METHODS: The birth weights of all dexamethasone-treated, singleton, live-born infants delivered at our hospital were compared with our overall obstetric population; a group of untreated infants frequency matched approximately 3:1 according to maternal race, infant sex, and gestational age at delivery; and an historical cohort of infants with an indication for dexamethasone but delivered in the 12 months before the introduction of corticosteroid therapy at our hospital. RESULTS: Dexamethasone-treated infants (n = 961), when compared with either the overall population (n = 122,629) or matched controls (n = 2808), had significantly lower birth weights after adjustment for week of gestation (P <.001). Compared with the historical cohort of infants, the average birth weight of dexamethasone-treated infants was smaller by 12 g at 24-26 weeks, 63 g at 27-29 weeks, 161 g at 30-32 weeks, and 80 g at 33-34 weeks' gestation. CONCLUSION: Antenatal dexamethasone administered to promote fetal maturation is associated with diminished birth weight.

Outcomes among term infants when two-hour postnatal pH is compared with pH at delivery.

OBJECTIVE: This study was undertaken to measure infant outcomes when pH at birth was compared with neonatal pH determined within 2 hours of age. STUDY DESIGN: We retrospectively studied term infants born between January 1, 1988, and August 31, 1998, who had umbilical artery blood pH measured at birth and again from the radial artery or umbilical artery within 2 hours after birth. Statistical significance was determined with the chi2 test. Odds ratios and 95% confidence intervals were calculated by means of the Mantel-Haenszel method. RESULTS: Data from a total of 1691 infants were analyzed: 178 (11%) had acidemia at birth (pH of <7.20) that persisted through the first 2 hours after birth; 110 (6%) had development of acidemia after birth; and 594 (35%) were born with a cord pH of <7.20 that improved after delivery. The remaining 809 infants (48%) did not have acidemia either at birth or during the neonatal period, and these served as the reference group. Seizures during the first 24 hours after birth were more likely among those infants with persistent acidemia (odds ratio, 13.0; 95% confidence interval, 6.3-26.7). The odds ratio for seizures among infants in whom acidemia developed after birth was 5.7 (95% confidence interval, 2.2-14.5). Other than the reference group, the infants who were born with acidemia that was corrected by 2 hours after birth had the lowest risk of seizures (odds ratio, 2.5; 95% confidence interval, 1.2-5.3). Significant differences in neonatal outcomes persisted after correction for anomalies. CONCLUSION: The direction of pH change from birth to the immediate neonatal period was significantly related to morbidity and mortality among term infants who were ill at birth or became ill shortly thereafter.

The continuing value of the Apgar score for the assessment of newborn infants.

BACKGROUND: The 10-point Apgar score has been used to assess the condition and prognosis of newborn infants throughout the world for almost 50 years. Some investigators have proposed that measurement of pH in umbilical-artery blood is a more objective method of assessing newborn infants. METHODS: We carried out a retrospective cohort analysis of 151,891 live-born singleton infants without malformations who were delivered at 26 weeks of gestation or later at an inner-city public hospital between January 1988 and December 1998. Paired Apgar scores and umbilical-artery blood pH values were determined for 145,627 infants to assess which test best predicted neonatal death during the first 28 days after birth. RESULTS: For 13,399 infants born before term (at 26 to 36 weeks of gestation), the neonatal mortality rate was 315 per 1000 for infants with five-minute Apgar scores of 0 to 3, as compared with 5 per 1000 for infants with five-minute Apgar scores of 7 to 10. For 132,228 infants born at term (37 weeks of gestation or later), the mortality rate was 244 per 1000 for infants with five-minute Apgar scores of 0 to 3, as compared with 0.2 per 1000 for infants with five-minute Apgar scores of 7 to 10. The risk of neonatal death in term infants with five-minute Apgar scores of 0 to 3 (relative risk, 1460; 95 percent confidence interval, 835 to 2555) was eight times the risk in term infants with umbilical-artery blood pH values of 7.0 or less (180; 95 percent confidence interval, 97 to 334). CONCLUSIONS: The Apgar scoring system remains as relevant for the prediction of neonatal survival today as it was almost 50 years ago.

Impact of head-to-abdominal circumference asymmetry on outcomes in growth-discordant twins.

OBJECTIVE: Our aim was to evaluate head-to-abdominal circumference asymmetry as a marker for adverse outcomes in growth-discordant twins. STUDY DESIGN: We conducted a retrospective cohort study of asymmetric and symmetric twins with > or =25% growth discordance, comparing their outcomes with those in concordant symmetric twins. Growth was termed asymmetric on the basis of a head circumference/abdominal circumference ratio at > or =95th percentile on ultrasonography performed < or =4 weeks before delivery. RESULTS: We evaluated 572 twin pairs. Asymmetric discordant twins were more likely than symmetric concordant twins to be delivered at < or =34 weeks' gestation (57% vs. 27%), to require intubation (36% vs. 7%), to remain in intensive care >1 week (36% vs 3%), and to have an outcome composite that included respiratory morbidity, intraventricular hemorrhage, sepsis, or neonatal death (29% vs 6%), all P<.05. Symmetric discordant and symmetric concordant twins had similar outcomes. CONCLUSIONS: Discordant twins with head-to-abdominal circumference asymmetry have an increased risk of morbidity. Moreover, in the absence of asymmetry, outcomes are comparable among discordant and concordant twins.

Maternal age and malformations in singleton births.

OBJECTIVE: To examine the effect of maternal age on incidence of nonchromosomal fetal malformations. METHODS: Malformations detected at birth or in the newborn nursery were catalogued prospectively for 102,728 pregnancies, including abortions, stillbirths, and live births, from January 1, 1988 to December 31, 1994. Maternal age was divided into seven epochs. Relative risks (RRs) were used to compare demographic variables and specific malformations. The Mantel-Haenszel chi(2) statistic was used to compare age-specific anomalies. Multiple logistic regression analysis was used to adjust for parity. RESULTS: Abnormal karyotypes were significantly more frequent in older women. After excluding infants with chromosomal abnormalities, the incidence of structurally malformed infants also was increased significantly and progressively in women 25 years of age or older. The additional age-related risk of nonchromosomal malformations was approximately 1% in women 35 years of age or older. The odds ratio for cardiac defects was 3.95 in infants of women 40 years of age or older (95% CI 1.70, 9.17) compared with women aged 20-24 years. The risks of clubfoot and diaphragmatic hernia also increased as maternal age increased. CONCLUSION: Advanced maternal age beyond 25 years was associated with significantly increased risk of fetuses having congenital malformations not caused by aneuploidy.

Effects of symmetric and asymmetric fetal growth on pregnancy outcomes.

OBJECTIVE: To assess the prevalence of head circumference to abdomen circumference (HC/AC) asymmetry among small for gestational age (SGA) fetuses, and to determine the likelihood of adverse outcomes among asymmetric and symmetric SGA infants compared with their appropriate for gestational age (AGA) counterparts. METHODS: In a retrospective cohort study, we analyzed consecutive live-born singletons of women who had antepartum sonography within 4 weeks of delivery and delivered between January 1, 1989 and September 30, 1996. A gestational age-specific HC/AC nomogram was derived from our sonographic database of 33,740 nonanomalous live-born singletons. Asymmetric HC/AC was defined as greater than or equal to the 95th percentile for gestational age. RESULTS: Among 1364 SGA infants, 20% had asymmetric HC/AC and 80% were symmetric. Asymmetric SGA infants were more likely to have major anomalies than symmetric SGA infants or AGA infants (14% versus 4% versus 3%, respectively; P <.001). After exclusion of anomalous infants, pregnancy-induced hypertension at or before 32 weeks' gestation and cesarean delivery for nonreassuring fetal heart rate were more common in the asymmetric SGA than the AGA group (7% versus 1% and 15% versus 3%, respectively; both P <.001). A neonatal outcome composite, including one or more of respiratory distress, intraventricular hemorrhage, sepsis, or neonatal death, was more frequent among asymmetric SGA than AGA infants (14% versus 5%, P =.001). Symmetric SGA infants were not at increased risk of morbidity compared with AGA infants. CONCLUSION: The minority of SGA fetuses with HC/AC asymmetry are at increased risk for intrapartum and neonatal complications.

Forty weeks and beyond: pregnancy outcomes by week of gestation.

OBJECTIVE: To assess pregnancy outcomes at 40, 41, and 42 weeks' gestation when labor induction is done routinely at 42 but not 41 weeks. METHODS: We reviewed all singleton pregnancies delivered at 40 or more weeks' gestation between 1988 and 1998 at Parkland Memorial Hospital, Dallas, Texas. We excluded women with hypertension, prior cesarean, diabetes, malformations, breech presentation, and placenta previa. Labor characteristics and neonatal outcomes of pregnancies at 41 and 42 weeks' gestation were compared with pregnancies that ended at 40 weeks. Women with certain dating criteria had induction of labor at 42 weeks. Gestational age was calculated from the last menstrual period (LMP), sonography when available, and clinical examination. If the fundal height between 18 and 30 weeks was within 2 cm of gestational age, the reported LMP was accepted as correct. Sonogram was used to calculate gestational age if a discrepancy was identified. Statistical analysis consisted of chi(2) and analysis of variance. RESULTS: We studied 56,317 pregnancies: 29,136 at 40 weeks, 16,386 at 41 weeks, and 10,795 at 42 weeks. Labor complications increased from 40 to 42 weeks, including oxytocin induction (2% versus 35%, P <.001), length of labor (5.5 +/- 4.9 versus 8.8 +/- 6. 5 hours, P <.001), prolonged second stage of labor (2% versus 4%, P <.001), forceps use (6% versus 9%, P <.001), and cesarean delivery (7% versus 14%, P <.001). Neonatal outcomes were similar in the three groups, including 5-minute Apgar score less than 4, admission to the neonatal intensive care unit (NICU), umbilical artery pH less than 7, seizures, and perinatal mortality. Sepsis was more frequent in the 42-week group than the other groups (0.1 versus 0.3%, P =. 001), as was admission to the NICU (0.4 versus 0.6%, P =.008). CONCLUSION: Routine labor induction at 41 weeks likely increases labor complications and operative delivery without significantly improving neonatal outcomes.

Correlation between amniotic fluid glucose concentration and amniotic fluid volume in pregnancy complicated by diabetes.

OBJECTIVE: Pregnancies complicated by diabetes are frequently characterized by an increased volume of amniotic fluid, and the pathophysiologic mechanism of this increase is not known. Our goal was to evaluate the relationship between amniotic fluid glucose concentration and the amniotic fluid index in pregnancies complicated by insulin-treated diabetes and to compare it with that seen in normal pregnancies. STUDY DESIGN: Amniotic fluid index and amniotic fluid glucose levels were measured before elective repeated cesarean delivery in 41 women with insulin-treated diabetes and in 35 women without diabetes. Only singleton gestations without anomalous fetuses were included. Women with diabetes were hospitalized for approximately 4 weeks before delivery, during which time glycemic control was optimized. Amniotic fluid index and amniotic fluid glucose concentration were correlated with each other and were compared between the groups with and without diabetes. RESULTS: The mean amniotic fluid index was significantly increased in the diabetes group (16.6 +/- 5.0 cm in the diabetes group vs 13.4 +/- 3.5 cm in the control group; P =.002). The amniotic fluid glucose concentration was also significantly greater in the diabetes group than in the control group (39 +/- 17 mg/dL in the diabetes group vs 24 +/- 11 mg/dL in the control group; P <.001). Among women with diabetes the amniotic fluid glucose concentration was significantly correlated with the amniotic fluid index (r = 0.32; P =.04), a correlation not found among the control women. The mean fasting blood glucose concentration among the women with diabetes for the week before amniocentesis was 82 +/- 11 mg/dL. CONCLUSION: The amniotic fluid index parallels the amniotic fluid glucose level among women with diabetes. This finding raises the possibility that the hydramnios associated with diabetes is a result of increased amniotic fluid glucose concentration.

Pregnancy outcomes after antepartum diagnosis of oligohydramnios at or beyond 34 weeks' gestation.

OBJECTIVE: Our purpose was to assess whether antepartum oligohydramnios is associated with adverse perinatal outcomes. STUDY DESIGN: Women delivered between July 1, 1991, and September 30, 1996, who underwent ultrasonography at >/=34 weeks' gestation were analyzed. Oligohydramnios was defined as an amniotic fluid index 50 mm. RESULTS: In our analysis of 6423 pregnancies, 147 (2.3%) were complicated by oligohydramnios. This complication was associated with increased labor induction (42% vs 18%; P <.001), stillbirth (1. 4% vs 0.3%; P <.03), nonreassuring fetal heart rate (48% vs 39%; P <. 03), admission to the neonatal intensive care nursery (7% vs 2%; P <. 001), meconium aspiration syndrome (1% vs 0.1%; P <.001), and neonatal death (5% vs 0.3%; P <.001). CONCLUSION: Antepartum oligohydramnios is associated with increased perinatal morbidity and mortality.

Use of Crinone vaginal progesterone gel for luteal support in in vitro fertilization cycles.

OBJECTIVE: To investigate the efficacy and safety of intravaginal Crinone 8% (Columbia Research Laboratories, Miami. FL) versus IM progesterone for luteal phase support after IVF-ET. DESIGN: Prospective open trial with comparison to historical controls. SETTING: University hospital. PATIENT(S): Two hundred six women undergoing IVF-ET. INTERVENTION(S): One hundred patients received Crinone vaginal progesterone gel (90 mg once daily) and 106 patients received IM progesterone (50 mg once daily) beginning on the evening of oocyte retrieval. MAIN OUTCOME MEASURE(S): Pregnancy and miscarriage rates, and midluteal serum progesterone levels. RESULT(S): Positive beta-hCG pregnancy rates, clinical pregnancy rates per transfer, and ongoing pregnancy rates were similar for the Crinone and IM progesterone groups. Women who received Crinone had higher rates of biochemical pregnancy loss but lower rates of clinical pregnancy loss (i.e., spontaneous abortion) than women who received IM progesterone. Midluteal serum progesterone concentrations were significantly higher in the IM progesterone group (94.3+/-8.8 ng/mL versus 57.7+/-7.4 ng/mL). Several women who received Crinone had vaginal bleeding 11-13 days after oocyte retrieval. CONCLUSION(S): For all age categories, positive beta-hCG and ongoing pregnancy rates were similar when Crinone or IM progesterone was given for luteal phase support in IVF-ET cycles, despite lower serum progesterone concentrations and higher rates of biochemical pregnancy loss with Crinone. Although the results of this study support the use of Crinone as an acceptable alternative for luteal support after IVF-ET, differences in bleeding patterns and rates of biochemical pregnancy loss demonstrate the need for a prospective randomized study.

Outcome of twin pregnancies according to intrapair birth weight differences.

OBJECTIVE: To assess the clinical significance of twin intrapair birth weight differences. METHODS: This was a retrospective study of twin pregnancy outcomes. Intrapair birth weight differences were stratified into the following six groups: 14% or less, 15-20%, 21-25%, 26-30%, 31-40%, and 41% or more using the larger infant as the growth standard. Statistical analysis was done using the Mantel-Haenzel chi2 test. RESULTS: We studied 1370 consecutive women who delivered at Parkland Hospital, Dallas, Texas, between January 1, 1988, and December 31, 1996, and had twin gestations and live births or fetal deaths within 7 days of delivery. Greater birth weight discordance was significantly associated with preterm delivery due to intervention (P<.001). Noncephalic-cephalic presentations and cesarean delivery were also associated with greater discordance (P = .001 and .02, respectively). Neonatal morbidities, including low birth weight, intensive care admission, and respiratory distress, were all associated with higher birth weight discordance. Fetal abnormalities were more common with increased discordance (P<.001). Greater birth weight discordance was also associated with intrauterine fetal death. There were no differences in outcome for the smaller compared with the larger twin of the twin pair. CONCLUSION: Twin birth weight discordance is problematic because severe divergent fetal growth increases the risk of fetal death and leads to obstetric intervention and consequent neonatal morbidity due to prematurity.